Idiotype Immunization Following High-Dose Therapy and Autologous Stem Cell Transplantation for Non-Hodgkin Lymphoma

Peter R. Holman,1,* Caitlin Costello,1,* Margarida deMagalhaes-Silverman,2 Sue Corringham,1 Januario Castro,1 Edward D. Ball1

The treatment of low- and intermediate-grade subtypes of malignant lymphoma continues to evolve. Mantle cell lymphoma (MCL) accounts for 6% of all non-Hodgkin lymphoma (NHL) and is generally considered incurable. Although high response rates can be achieved with initial chemotherapy, median survival is only 3-4 years. Intensified consolidation with high-dose therapy (HDT) and autologous stem cell transplantation (ASCT) has been reported to improve progression-free survival (PFS), but most patients eventually relapse. Indolent lymphoma accounts for 35% of all NHL and is associated with a median survival of 9 years. Similar to MCL, it is also generally considered incurable, and the PFS also appears to be improved following HDT/ASCT. We initiated a pilot study to evaluate idiotype (Id) vaccination following HDT and ASCT for patients with MCL, indolent, and transformed NHL to evaluate the ability of Id-keyhole limpet hemocyanin (KLH) to in- duce immune responses, and to evaluate overall survival (OS) and PFS. We treated 15 patients: 8 with MCL, 4 with follicular lymphoma, 1 with small lymphocytic lymphoma, and 2 with transformed lymphoma. After a median follow-up of approximately 6.3 years (range: 1-9), PFS and OS at 9.05 years from time of ASCT are 59% and 52%, respectively. Biol Blood Marrow Transplant 18: 257-264 (2012) Ó 2012 American Society for Blood and Marrow Transplantation KEY WORDS: Non-Hodgkin lymphoma, Autologous stem cell transplantation, Idiotype vaccination,

INTRODUCTION cell transplantation (ASCT) has been reported to improve progression-free survival (PFS), but most The treatment of low- and intermediate-grade patients ultimately relapse [1-4]. subtypes of non-Hodgkin lymphomas (NHL) con- The use of idiotype (Id) immunization to develop tinues to evolve. The introduction of immunothera- an anti-Id has been dem- peutic strategies has become an attractive means of onstrated as a promising approach to the treatment treatment, particularly with the use of passive immu- of B cell lymphomas, and could result in more durable notherapy (eg, rituximab). High response rates can remissions and improved overall survival (OS) than be achieved with chemotherapy, monoclonal anti- with standard chemoimmunotherapeutic options [5-7]. bodies, and radioimmunotherapy. However, progres- Immunoglobulin (Ig) molecules on the surface of sion of disease is frequent. Intensified consolidation clonal B cells in NHL can be used as a tumor-specific with high-dose therapy (HDT) and autologous stem target for immunotherapy. A unique Ig receptor ex- pressed on the malignant B cell surface contains a specific antigen-recognition region, the Id, which From the 1Moores UCSD Center, Blood and Marrow can be targeted as a strong antigen for the induction Transplantation Division, La Jolla, California; and 2University of an anti-Id immune response. The coupling of of Iowa, Iowa City, Iowa. the Id protein to keyhole limpet hemocyanin (KLH) Financial disclosure: See Acknowledgments on page 262. *The first 2 authors contributed equally to this article. and simultaneous local administration of granulocyte- Correspondence and reprint requests: Edward D. Ball, MD, macrophage colony-stimulating factor (GM-CSF) Moores UCSD Cancer Center, Division of Blood and Marrow produces an augmented immune response targeted Transplantation, 3855 Health Sciences Drive MC-0960, La at malignant B cells while sparing normal B cells Jolla, CA 92093 (e-mail: [email protected]). [5,8]. Studies in animals and humans have shown Received April 19, 2011; accepted June 27, 2011 Ó 2012 American Society for Blood and Marrow Transplantation the effectiveness of the to target Id 1083-8791/$36.00 and kill lymphoma cells [9-12]. Treatment with doi:10.1016/j.bbmt.2011.06.011 monoclonal anti-Id can cause tumor

257 258 P. R. Holman et al. Biol Blood Marrow Transplant 18:257-264, 2012 regression and possibly induce long-term clinical patients in first CR [28,33]. Although recent data remissions [12,13]. has been promising, relapse rates after HDT and Invariably, early clinical trials in patients with B ASCT remain high [26,28,33-36]. cell lymphomas have shown that Id vaccination is With this background, we initiated a pilot study effective in eliciting specific anti-Id responses, accom- evaluating Id vaccination following HDT and ASCT panied by clinical benefit [14,15]. Long-term follow-up for patients with MCL, indolent NHL, and trans- of these patients has shown improved clinical out- formed NHL (TL) to explore the feasibility and effi- comes with prolonged PFS and OS [5]. Recent trials cacy of this post-ASCT immunotherapeutic strategy have evaluated the use of Id vaccination in patients to induce and maintain complete clinical or molecular with follicular non-Hodgkin lymphoma (NHL[FL]). remissions. Early trials showed tumor regression and durable ob- jective responses to vaccination in pretreated patients with relapsed/refractory NHL used as a single agent, METHODS or following rituximab immunotherapy [16-19]. Prior studies have demonstrated a strong inverse Patient Population correlation between the presence of detectable malig- Between April 2001 and September 2006, 32 pa- nancy and the laboratory detection of a cellular or hu- tients with NHL were enrolled in a pilot study to eval- moral Id-specific immune response [5,20]. Enhanced uate the feasibility, safety, and potential efficacy of Id immune responsiveness to vaccination that was seen immunization following HDT and ASCT. Eligible in patients in complete remission (CR) at the time of patients were between the ages of 18 and 75, had a vaccination prompted the hypothesis that a Karnofsky Performance Status of $70%, and had was most effective in patients with minimal or no received any number of prior chemotherapy regimens. detectable residual disease. This suggested the Patients may not have undergone prior HDT and consideration of HDT followed by ASCT as a means ASCT. Histologic confirmation of lymphoma was re- to achieve a maximal response to therapy while quired and included patients with small lymphocytic providing an ideal opportunity to mount an effective lymphoma (SLL), follicular small cleaved cell, follicu- immune response via Id vaccination. Davis et al. [21] lar mixed small and large cell, MCL, or TL. Patients demonstrated the feasibility of this concept in 12 pre- were required to have a left ventricular ejection frac- treated patients with refractory or relapsed B cell lym- tion .40%, diffusion lung capacity of carbon monox- phomas, producing prolonged remissions particularly ide .40% of predicted, creatinine\1.8 mg/dL, and be in patients with FL. The applicability of Id vaccination a candidate for ASCT. Patients were excluded for after ASCT in other subtypes of B-cell lymphoma has known central nervous system lymphoma or menin- not yet been evaluated. geal lymphomatosis, human immunodeficiency virus, Mantle cell lymphoma (MCL) was originally de- or chronic inflammatory disorders requiring the scribed more than 30 years ago but was finally ac- continued use of glucocorticoids or other immunosup- cepted as a separate entity when it became evident pressive medications. The population included 16 pa- that the t(11;14)(q12;q32) translocation was consis- tients with FL, 10 with MCL, 3 with TL, 2 with SLL, tently present [22,23]. MCL accounts for 6% of all and 1 with marginal zone lymphoma (MZL). The NHL and is often indolent or moderately aggressive institutional review boards of the participating centers at diagnosis, but with time the disease invariably approved the study. Written informed consent was becomes clinically aggressive and chemotherapy obtained from all participants before enrollment. refractory. It has shown the worst long-term survival among all B cell lymphoma subtypes, and is generally thought to be incurable [24]. Although high response Treatment Design rates can be achieved with initial chemotherapy for A lymph node biopsy, peripheral blood draw, MCL, median survival is only 3-4 years [25].Data or bone marrow biopsy was performed on eligible of cohorts following HDT and ASCT suggest patients to provide material for the generation of a higher event-free survival (EFS) and OS compared tumor-specific Id. Patients whose lymphoma cells with historic controls [2,26-32]; however, no expressed surface Ig were then eligible to continue randomized trial has reached conclusive results [2]. on the study. All patients had measurable disease after All data suggest that there is no disease-free plateau, obtaining tissue for vaccine production. Following and therefore relapse is likely in most patients with tissue collection, patients proceeded to undergo a MCL. Data from the Nordic Lymphoma Group standard cytoreductive chemotherapy regimen before MCL2 study and the M. D. Anderson Cancer Center, stem cell mobilization, and HDT followed by however, have recently shown that intensified con- ASCT. Cytoreductive chemotherapy was chosen solidation with HDT and ASCT could provide and administered at the discretion of the treating long-term disease control in chemotherapy-na€ıve physician, although fludarabine and rituximab were Biol Blood Marrow Transplant 18:257-264, 2012 Idiotype Immunization Following High-Dose Therapy and ASCT for NHL 259 discouraged because of their known effects on the point measured, a positive response to KLH was indi- cellular and humoral immune systems, respectively. cated by a result above the mean plus 3 standard devi- Vaccination was initiated at least 3 months after trans- ations observed in the controls. A positive result to plantation, and followed an immunization schedule as Id was indicated by a result 3-fold higher than that outlined below. Patients have subsequently been fol- observed with the irrelevant control Id. lowed for clinical and radiographic signs of relapse. Disease Evaluation Vaccine Production Patients underwent routine staging by clinical ex- Id was produced by a proprietary recombinant amination, bone marrow, and peripheral blood evalu- technology from the tumor-specific Ig light and heavy ation, and computed tomography (CT) or magnetic chain genes captured from each individual patient’s resonance image (MRI) evaluation, before induction lymphoma cells, as previously described [37]. These chemotherapy, before HDT/ASCT, and at 30 days genes were molecularly identified by polymerase chain following ASCT. Repeat evaluations of disease status reaction (PCR) amplification and cloned into a dual were performed at 3, 6, 9, and 14 months post- gene baculovirus expression vector [38] containing ASCT. All patients were monitored closely for toxicity IgG1 (heavy chain, Vh) and kappa or lambda (light during the study period. For non-MCL patients, chain, VL) constant regions. Following identification molecular evaluation of the bone marrow/peripheral of the tumor derived Ig Vh and VL region sequences, blood using PCR for the t(14;18) were obtained pre- heavy and light chain coding products were cloned, ASCT. No patients were found to have this chromo- and the Ig was subsequently coupled to KLH using somal abnormality. glutaraldehyde [14]. Statistical Methods Vaccine Administration The durations of PFS and OS were calculated from Patients received a monthly subcutaneous vaccina- the date the patient underwent ASCT until the date of tion of Id-KLH together with 250 mg GM-CSF at a disease progression (PFS) and the date of death from minimum of 3 months following ASCT, and vaccina- any cause (OS), or last follow-up as appropriate. The tion was repeated for 4 consecutive months. This was probabilities of these outcomes as a function of time followed by a final vaccination 2 months thereafter. were determined by the Kaplan-Meier method. A total of 250 mg GM-CSF was administered alone by daily injections for 3 days following each Id-KLH vaccination to enhance the immunogenicity and anti- RESULTS tumor effects, consistent with previous studies to enhance the efficacy of the vaccine [37,39]. Patient Characteristics From April 2001 to September 2006, of the 32 pa- Cellular and Humoral Response Evaluation tients enrolled in this pilot study, 15 patients received To evaluate the ability of Id-KLH/GM-CSF to in- Id immunization following HDT and ASCT. All duce cellular and immune responses, peripheral blood patients received HDT with Carmustine, etoposide, mononuclear cells were obtained and cultured with cytarabine, and melphalan (BEAM) except for 1 MCL KLH, autologous Id, or a control patient Id. The patient who received cyclophospohomide, etoposide, blood samples were obtained before each vaccination and carmustine (CEB), and 1 TL patient who received and at 4 weeks following the completion of therapy. 131I-tositumomab, cytarabine, and etoposide. Of the 1 The frequency of CD4 T cells that stain for cytoplas- 17 patients who came off study before receiving im- mic (IFN)-g or tumor necrosis factor munization, 12 had FL. Of these FL patients, 3 with- (TNF)-a was determined. A positive T cell response drew consent, 1 underwent allogeneic stem cell to KLH was indicated by a result above the mean transplantation, 1 had an inadequate stem cell collec- plus 3 standard deviations observed in the controls. A tion, and 1 was excluded for chronic steroid use result- positive T cell response to Id is indicated by a result ing from BCNU toxicity post-ASCT. could 3-fold higher than that observed with the irrelevant not be produced for 6 FL patients. Of the remaining control Ig. 5 patients, vaccines could not be made for 1 patient To evaluate humoral immune responses, serial di- with TL, and 4 patients were ultimately not recom- lutions of serum samples were added to wells contain- mended for ASCT. Fifteen patients received Id immu- ing Id Fab fragments, KLH-coated wells, Id-KLH, or nization: 8 with MCL; 4 with FL; 1 with SLL; and a sham control. The presence of bound antibody was 2withTL(Table 1) The median number of prior reg- detected using a goat anti-human IgG horseradish imens for all patients was 2 (range: 1-5), and all but 1 peroxidase-conjugated antibody preparation in a stan- patient demonstrated chemosensitivity before ASCT. dard enzyme-linked immunosorbent assay. At any Following induction therapy, 5 patients proceeded to 260 P. R. Holman et al. Biol Blood Marrow Transplant 18:257-264, 2012

Table 1. Patient Characteristics

No. of Prior Disease Response Time from ASCT to Patient No. Age Sex Histology Regimens Before ASCT Vaccination (Months)

1 63 M MCL 2 CR 6 2 61 M MCL 3 PR 3 3 56 M MCL 1 CR 6 4 62 M MCL 2 CR 4 5 60 M MCL 2 CR 3 6 52 M MCL 1 CR 4 7 66 M MCL 1 CR 3 8 50 M MCL 1 CR 7 954MFL 5 PR 3 10 54 F FL 1 PR 4 11 54 F FL 3 PR 4 12 48 M FL 4 PR 3 13 51 M TL 5 PR 6 14 66 M TL 2 PR 3 15 27 M SLL 3 SD 5

ASCT indicates autologous stem cell transplant; MCL, mantle cell lymphoma; FL, follicular lymphoma; TL, transformed lymphoma; SLL, small lymphocytic lymphoma; CR, complete response; PR, partial response; SD, stable disease.

HDT and ASCT in a partial remission (PR), 5 in first post-ASCT. All but 1 patient completed the immuni- CR, and 4 in second CR. One patient proceeded after zation schedule and received all 5 vaccinations. Patient first relapse. For MCL patients, the median number of 14 received only 2 vaccines because of evidence of pro- prior regimens was 2 (range: 1-5), including rituximab, gressive disease. cyclophosphamide, doxorubicin, vincristine, and pred- nisone (R-CHOP), and cyclophosphamide, vincris- tine, doxorubicin, and dexamethasone (hyperCVAD) Clinical Responses with or without rituximab. Five of the 8 MCL patients The median follow-up after ASCT and Id vaccina- received hyperCVAD as treatment. FL patients had tion is 6 years, ranging from 1 to 9 years. Of the 15 previously received a variety of regimens, including: treated patients, 8 are alive and are in CR (Table 2). fludarabine; cyclophosphamide, vincristine, and pred- Six patients died of progressive disease, and 1 FL pa- nisone (CVP); CHOP; rituximab alone or in combina- tient died of myelodysplasia that progressed to acute tion; and 90Y-ibritumomab. No patient received myeloid leukemia (AML) at 34 months post-ASCT rituximab as part of a maintenance regimen, just before without evidence of lymphoma. All 8 patients with or after transplantation, or for the purpose of graft MCL achieved CR following ASCT, and 5 have re- purging. mained in continued CR (CCR) between 76 and 108 After ASCT and before immunization, all but 1 months post-ASCT. Three patients with MCL patient patient had stable disease, a PR, or a CR. Patients re- relapsed at 10, 13, and 47 months after ASCT. Of the ceived the first vaccination between 3 and 7 months 3 FL patients who achieved CR, 2 continue in CR at

Table 2. Clinical Responses

Response Response Response at Response at Time Since Patient Histology Prevaccine 1 Prevaccine 4 9 Months 14 Months ASCT (Months) Status

1 MCL CR CR CR CR 108 Alive—CR 2 MCL PR CR CR PD 23 Expired—PD 3 MCL CR CR CR CR 72 Expired—PD 4 MCL CRu CRu CRu CR 94 Alive—CR 5 MCL CR CR CR CR 90 Alive—CR 6 MCL CR CR PD Off study 20 Expired—PD 7 MCL CR CR CR CR 76 Alive—CR 8 MCL CR CR CR CR 79 Alive—CR 9 FL PR CRu CR CR 34 Expired— MDS/AML 10 FL SD SD SD SD 106 Alive—CR 11 FL CR CR CR CR 80 Alive—CR 12 FL PD PD PD PD 22 Expired—PD 13 TL SD SD SD SD 91 Alive—CR 14 TL CR PD Off Study — 6 Expired—PD 15 SLL CR CR CR CR 26 Expired—PD

MCL indicates mantle cell lymphoma; FL, follicular lymphoma; TL, transformed lymphoma; SLL, small lymphocytic lymphoma; CR, complete response; CRu, complete response unconfirmed; PR, partial response; SD, stable disease; ASCT, autologous stem cell transplant; PD, progressive disease; MDS/AML, myelodysplastic syndrome with progression to acute myelogenous leukemia. Biol Blood Marrow Transplant 18:257-264, 2012 Idiotype Immunization Following High-Dose Therapy and ASCT for NHL 261

80 and 106 months post-ASCT. One patient with TL achieved a CR post-ASCT, but had progressive disease at month 45. That patient subsequently underwent al- logeneic stem cell transplantation and has remained in a CCR. With a median follow-up of 6.3 years (range: 1-9), the PFS and OS at 9.05 years from the time of ASCT are 59% and 52%, respectively (Figures 1 and 2). After a median follow-up of up to 6.3 years, PFS and OS for MCL at 9.05 years from the time of ASCT was 62.5% and 60%, respectively. No patient with MCL showed disease progression after 4 years or died after 6 years.

Toxicities Id immunizations were well tolerated, with injec- tion site reactions being the most commonly reported Figure 2. OS of patients who received idiotype vaccination after ASCT adverse events. Grade 3 toxicities included leucopenia for NHL. in 1 patient, vitreous hemorrhage in 1 patient, liver abscess in 1 patient secondary to biliary stent obstruc- anti-KLH and anti-Id cellular responses, 1 developed tion, infection in 1 patient, and syncope in 1 patient. anti-Id cellular response only, and 1 was not tested. As stated previously, 1 patient developed a secondary The patient with MCL who relapsed after 47 months treatment-related AML. All of these toxicities were also had both anti-Id and anti-KLH cellular responses. thought to be transplant-related events, not likely Three of the 4 FL patients developed anti-KLH related to Id vaccination. No limiting, sustained, or humoral responses, and 2 developed anti-Id humoral re- delayed toxicities were identified, and no adjust- sponses. Of the 3 FL patients who obtained a durable CR, ments were made to the vaccine formulation because 2 developed an anti-Id and anti-KLH cellular response, of toxicity. and the third was not tested. A lack of viable cells for eval- uation upon shipment to a reference lab limited the eval- Immune Responses uation of an immune response for several patients. Specific anti-Id and anti-KLH responses, both hu- moral and cellular, were noted in the majority of DISCUSSION treated patients (Table 3). Anti-KLH and anti-Id hu- moral responses were noted as early as after the second This pilot study illustrates the use of Id vaccination vaccine, although the majority of responders were as a feasible immunotherapeutic intervention follow- noted to be after the third vaccine. The patients who ing ASCT for NHL. Early and Id-specific immune developed a cellular anti-KLH and anti-Id response did so after the second vaccine, although it was noted Table 3. Immune Responses to Id Vaccination Post-ASCT to have occurred after the first vaccine in 3 patients. Of the 5 patients with MCL with a CCR, 3 developed Humoral Cellular Responsiveness Responsiveness

Patient Histology Anti-KLH Anti-Id Anti-KLH Anti-Id

1MCL++++ 2 MCL 2222 3 MCL + NSR + + 4MCL++++ 5 MCL 22++ 6 MCL + + NT NT 7 MCL + 2 NT NT 8 MCL 2 NT 2 + 9FL++++ 10 FL + NSR + + 11 FL + + NT NT 12 FL 22NT NT 13 TL + + 22 14 TL NT NT NT NT 15 SLL + 2 NT NT

Id indicates idiotype; ASCT, autologous stem cell transplantation; KLH, keyhole limpet hemocyanin; MCL, mantle cell lymphoma; FL, follicular Figure 1. PFS of patients who received idiotype vaccination after lymphoma; TL, transformed lymphoma; SLL, small lymphocytic lym- ASCT for NHL. phoma; NSR, nonspecific response; NT, not tested. 262 P. R. Holman et al. Biol Blood Marrow Transplant 18:257-264, 2012 responses were seen in vaccinated patients post-ASCT alone is insufficient for cure [2,51-56]. The MCL2 as treatment for both indolent and more aggressive Study showed encouraging results for the use of lymphomas. Durable clinical responses were seen intensive immunochemotherapy followed by ASCT, with this approach, even in this heavily pretreated pop- with no relapses seen after 5 years [28]. Updated data ulation. The early appearance and durability of specific after a median follow-up of 5.6 years reported a 10-year immune responses may be attributable to the adminis- OS of 58%; however, late relapses were seen [57]. tration of Id immunization during a window of immune Few studies have evaluated the use of Id vaccina- reconstitution following HDT/ASCT. Early data on tion in the posttransplantation setting [21].This tumor-specific Id vaccines for the treatment of NHL study provides follow-up after 9 years in patients suggest that its use would be most effective in patients with NHL who underwent HDT/ASCT followed with minimal or no detectable residual disease [5]. The by Id vaccination. The PFS and OS, 59% and 52%, use of HDT/ASCT provides an ideal opportunity to respectively, suggest the possibility of long-term dis- note effective immune responses to a vaccine based on ease control using this strategy. The 9-year PFS and the unique Ig protein expressed by tumor cells. OS of MCL patients, 62.5% and 60%, respectively, Our study confirms previous data from animal also support the notion of improved long-term out- models that establish the ability of the immune system comes in a lymphoma historically associated with to reconstitute and mount robust immune responses as a poor prognosis. Because late relapses are of concern early as 2 weeks after myeloablative therapy [40,41]. after transplantation for MCL, no patient showed T cell reconstitution may depend on the maturation disease progression after 4 years or died after 6 years of peripheral cells present in the graft during in this study. the posttransplantation setting of minimal residual Long-term follow-up of this population shows disease. As demonstrated in murine studies, the promising effects of Id vaccination in the posttrans- maturing T cells may be antigen driven and with the plantation setting on PFS and OS. Of the 15 patients added advantage of immune reconstitution posttrans- treated, 8 (53%) have shown durable remissions, 5 of plantation, a specific window may be created for the which were seen in patients with MCL. Detailed anal- induction of a vigorous Id-specific immune response ysis of this subset of MCL patients showed a group of [42]. The use of HDT may lead to a depletion of male patients, age 50-66, stage IV disease, Karnofsky regulatory T cells. A loss of this population of T lym- Performance Status .70%, and few or no medical phocytes, crucial in the control of T cell-mediated comorbidities. Induction regimens included either autoimmunity by suppressing the proliferation and hyperCVAD or CHOP, with or without rituximab. production of other T cells, could allow for Three of these patients underwent ASCT in first CR, an even more robust immune response. and 2 patients in second CR. The similarities among Clinical studies of the use of Id vaccine in NHL these long-term survivors with MCL may provide have largely focused on its use in the pretransplantation a specific subset of patients to target for successful Id settinginFL[8,16,19,37,43,44]. Despite early vaccination in the future. enthusiasm, 2 phase III studies showed no benefit of This experience supports the concept of Id vacci- Id vaccine after induction chemotherapy for FL. nation in the post-ASCT setting as a safe, feasible, These data have assuaged its use and halted further and effective intervention in patients with NHL. Our production of the respective vaccines [37,45].Recent data suggests the idea that there is an immune compo- data on the use of rituximab in FL for in vivo purging nent that can be exploited in this setting, and this and maintenance may also potentially overshadow the strategy may extend to more aggressive lymphomas. proposed benefit of Id vaccination [46]. These data Id vaccination in patients with MCL who undergo were not available before initiating this study, and ritux- ASCT shows early promise of providing durable imab was not used in these manners. remissions and prolonged OS. Further investigation The potential benefit of Id vaccination in MCL is of the use of Id vaccination in the posttransplantation not well established. Early studies showed the safety setting for MCL is necessary on a larger scale to con- and feasibility of Id vaccination following chemother- firm these findings. apy in patients with MCL [47,48]. Anti-Id immune This study presents a form of immunotherapy that responses were observed, even after rituximab-based shows favorable effects on long-term disease control chemotherapy, showing that severe B cell depletion in a subset of patients with MCL. We hope that these re- does not impair T cell priming in humans [49]. Our sults spur a renewed interest in continuing this approach. preliminary data showed that early development of ro- bust immune responses may translate into prolonged posttransplantation disease-free survival (DFS) in ACKNOWLEDGMENT MCL [50]. HDT/ASCT has been shown to improve the clini- Financial disclosure: The authors have no conflicts cal outcomes in MCL, a disease in which chemotherapy of interest to disclose. Biol Blood Marrow Transplant 18:257-264, 2012 Idiotype Immunization Following High-Dose Therapy and ASCT for NHL 263

REFERENCES mitumprotimut-T (Id-KLH, FavID) active immunotherapy. Blood. 2007;110. 1. Khouri IF, Romaguera J, Kantarjian H, et al. Hyper-CVAD 19. Koc ON, Redfern C, Wiernik PH, et al. A phase 2 trial of immu- and high-dose methotrexate/cytarabine followed by stem-cell notherapy with mitumprotimut-T (Id-KLH) and GM-CSF transplantation: an active regimen for aggressive mantle-cell following rituximab in follicular B-cell lymphoma. J Immun- lymphoma. J Clin Oncol. 1998;16:3803-3809. other. 2010;33:178-184. 2. Dreyling M, Lenz G, Hoster E, et al. Early consolidation by 20. Schuster S, Neelapu S, Nichols C, et al. Idiotype vaccine myeloablative radiochemotherapy followed by autologous therapy (BiovaxID) in follicular lymphoma in first complete stem cell transplantation in first remission significantly prolongs remission; phase III clinical trial results. JClinOncol.2009; progression-free survival in mantle-cell lymphoma: results of 27(18 suppl):2. a prospective randomized trial of the European MCL Network. 21. Davis TA, Hsu FJ, Caspar CB, et al. Idiotype vaccination Blood. 2005;105:2677-2684. following ABMT can stimulate specific anti-idiotype immune 3. Schouten HC, Qian W, Kvaloy S, et al. High-dose therapy responses in patients with B-cell lymphoma. Biol Blood Marrow improves progression-free survival and survival in relapsed fol- Transplant. 2001;7:517-522. licular non-Hodgkin’s lymphoma: results from the randomized 22. Banks PM, Chan J, Cleary ML, et al. Mantle cell lymphoma. A European CUP trial. J Clin Oncol. 2003;21:3918-3927. proposal for unification of morphologic, immunologic, and mo- 4. Mills W, Chopra R, McMillan A, Pearce R, Linch DC, lecular data. Am J Surg Pathol. 1992;16:637-640. Goldstone AH. BEAM chemotherapy and autologous bone 23. Zucca E, Stein H, Coiffier B. European Lymphoma Task Force marrow transplantation for patients with relapsed or refractory (ELTF): report of the workshop on mantle cell lymphoma non-Hodgkin’s lymphoma. J Clinical Oncol. 1995;13:588-595. (MCL). Ann Oncol. 1994;5:507-511. 5. Hsu FJ, Caspar CB, Czerwinski D, et al. Tumor-specific 24. Zucca E, Roggero E, Pinotti G, et al. Patterns of survival in idiotype vaccines in the treatment of patients with B-cell mantle cell lymphoma. Ann Oncol. 1995;6:257-262. lymphoma—long-term results of a clinical trial. Blood. 1997; 25. Bosch F, Lopez-Guillermo A, Campo E, et al. Mantle cell lym- 89:3129-3135. phoma: presenting features, response to therapy, and prognostic 6. Weng WK, Czerwinski D, Timmerman J, Hsu FJ, Levy R. Clin- factors. Cancer. 1998;82:567-575. ical outcome of lymphoma patients after idiotype vaccination is 26. Khouri IF, Romaguera J, Kantarjian H, et al. Hyper-CVAD and correlated with humoral immune response and immunoglobulin high-dose methotrexate/cytarabine followed by stem-cell G Fc receptor genotype. J Clin Oncol. 2004;22:4717-4724. transplantation: an active regimen for aggressive mantle-cell 7. Ai WZ, Tibshirani R, Taidi B, Czerwinski D, Levy R. Anti- lymphoma. J Clin Oncol. 1998;16:3803-3809. idiotype antibody response after vaccination correlates with 27. Khouri IF, Saliba RM, Okoroji GJ, Acholonu SA, Champlin RE. better overall survival in follicular lymphoma. Blood. 2009;113: Long-term follow-up of autologous stem cell transplantation in 5743-5746. patients with diffuse mantle cell lymphoma in first disease remis- 8. Bendandi M, Gocke CD, Kobrin CB, et al. Complete sion: the prognostic value of beta2-microglobulin and the tumor molecular remissions induced by patient-specific vaccination score. Cancer. 2003;98:2630-2635. plus granulocyte-monocyte colony-stimulating factor against 28. Geisler CH, Kolstad A, Laurell A, et al. Long-term progression- lymphoma. Nat Med. 1999;5:1171-1177. free survival of mantle cell lymphoma after intensive front-line 9. Campbell MJ, Esserman L, Byars NE, Allison AC, Levy R. immunochemotherapy with in vivo-purged stem cell rescue: Idiotype vaccination against murine B cell lymphoma. Humoral a nonrandomized phase 2 multicenter study by the Nordic and cellular requirements for the full expression of antitumor Lymphoma Group. Blood. 2008;112:2687-2693. immunity. J Immunol. 1990;145:1029-1036. 29. Gianni AM, Magni M, Martelli M, et al. Long-term remission in 10. Campbell MJ, Esserman L, Levy R. Immunotherapy of established mantle cell lymphoma following high-dose sequential chemo- murine B cell lymphoma. Combination of idiotype immunization therapy and in vivo rituximab-purged stem cell autografting and cyclophosphamide. J Immunol. 1988;141:3227-3233. (R-HDS regimen). Blood. 2003;102:749-755. 11. Tao MH, Levy R. Idiotype/granulocyte-macrophage colony- 30. Mangel J, Leitch HA, Connors JM, et al. Intensive chemother- stimulating factor fusion protein as a vaccine for B-cell lym- apy and autologous stem-cell transplantation plus rituximab is phoma. Nature. 1993;362:755-758. superior to conventional chemotherapy for newly diagnosed 12. Miller RA, Maloney DG, Warnke R, Levy R. Treatment of advanced stage mantle-cell lymphoma: a matched pair analysis. B-cell lymphoma with monoclonal anti-idiotype antibody. Ann Oncol. 2004;15:283-290. N Engl J Med. 1982;306:517-522. 31. Evens AM, Winter JN, Hou N, et al. A phase II clinical trial of 13. Meeker TC, Lowder J, Maloney DG, et al. A clinical trial of intensive chemotherapy followed by consolidative stem cell anti-idiotype therapy for B cell malignancy. Blood. 1985;65: transplant: long-term follow-up in newly diagnosed mantle 1349-1363. cell lymphoma. Br J Haematol. 2008;140:385-393. 14. Kwak LW, Campbell MJ, Czerwinski DK, Hart S, Miller RA, 32. Dreger P, Rieger M, Seyfarth B, et al. Rituximab-augmented Levy R. Induction of immune responses in patients with B-cell myeloablation for first-line autologous stem cell transplantation lymphoma against the surface-immunoglobulin idiotype expressed for mantle cell lymphoma: effects on molecular response and by their tumors. NEnglJMed. 1992;327:1209-1215. clinical outcome. Haematologica. 2007;92:42-49. 15. Hsu FJ, Kwak L, Campbell M, et al. Clinical trials of idiotype- 33. Tam CS, Bassett R, Ledesma C, et al. Mature results of the specific vaccine in B-cell lymphomas. Ann N Y Acad Sci. 1993; M. D. Anderson Cancer Center risk-adapted transplantation 690:385-387. strategy in mantle cell lymphoma. Blood. 2009;113:4144-4152. 16. Redfern CH. Phase II trial of idiotype vaccination in previously 34. Milpied N, Gaillard F, Moreau P, et al. High-dose therapy with treated patients with indolent non-Hodgkin’s lymphoma result- stem cell transplantation for mantle cell lymphoma: results and ing in durable clinical responses. JClinOncol. 2006;24:3107-3112. prognostic factors, a single center experience. Bone Marrow 17. Koc ON, Redfern C, Wiernik PH, et al. Active immunotherapy Transplant. 1998;22:645-650. with FavId(R) (Id/KLH) following rituximab induction: long- 35. Vandenberghe E, Ruiz de Elvira C, Loberiza FR, et al. Outcome term follow-up of response rate improvement (RRI) and disease of autologous transplantation for mantle cell lymphoma: a study progression in follicular lymphoma patients (pts). Blood. by the European Blood and Bone Marrow Transplant and 2006;108. Autologous Blood and Marrow Transplant Registries. Br J 18. Koc ON, Redfern C, Wiernik PH, Rosenfelt F, Winter JN. Haematol. 2003;120:793-800. Continued late conversion to complete remission (CR/CRu) 36. Freedman AS, Neuberg D, Gribben JG, et al. High-dose che- and durability of remission (DUR) in pts with B-cell follicular moradiotherapy and anti-B-cell monoclonal antibody-purged lymphoma (FL) treated with rituximab followed by autologous bone marrow transplantation in mantle-cell 264 P. R. Holman et al. Biol Blood Marrow Transplant 18:257-264, 2012

lymphoma: no evidence for long-term remission. J Clin Oncol. 47. Leonard J, Vose JM, Timmerman JM, et al. Recombinant 1998;16:13-18. idiotype-KLH vaccination (MyVaxÔ) following CHOP chemo- 37. Freedman A, Neelapu SS, Nichols C, et al. Placebo- therapy in mantle cell lymphoma. Blood. 2003;102(105a). controlled phase III trial of patient-specific immunotherapy 48. Wilson WH, Neelapu S, Rosenwald A, et al. Idiotype vaccine with mitumprotimut-T and granulocyte-macrophage colony- and dose-adjusted EPOCH-rituximab treatment in untreated stimulating factor after rituximab in patients with follicular mantle cell lymphoma: preliminary report on clinical outcome lymphoma. J Clin Oncol. 2009;27:3036-3043. and analysis of immune response. In: American Society of Hema- 38. Jones I, Morikawa Y. Baculovirus vectors for expression in insect tology 45th Annual Meeting and Exposition; 2003 December 6-9; cells. Curr Opin Biotechnol. 1996;7:512-516. San Diego, CA. Abstract 358. 39. Kwak LW, Young HA, Pennington RW, Weeks SD. Vaccination 49. Neelapu SS, Kwak LW, Kobrin CB, et al. Vaccine-induced with syngeneic, lymphoma-derived immunoglobulin idiotype tumor-specific immunity despite severe B-cell depletion in man- combined with granulocyte/macrophage colony-stimulating tle cell lymphoma. Nat Med. 2005;11:986-991. factor primes mice for a protective T-cell response. Proc Natl 50. Holman P, Corringham S, Bashey A, et al. Early and robust Acad Sci U S A. 1996;93:10972-10977. immune responses to idiotype (Id) vaccination occur in mantle 40. Kwak LW, Campbell M, Levy R. Idiotype vaccination post- cell lymphome (MCL) and indolent lymphoma (IL) patients fol- bone marrow transplantation for B-cell lymphoma: initial stud- lowing autologous stem cell transplantation. Blood. 2003;102. ies in a murine model. Cancer Detect Prev. 1991;15:323-325. abstract #3345. 41. Kwak LW, Campbell MJ, Zelenetz AD, Levy R. Combined 51. Dreger P, Martin S, Kuse R, et al. The impact of autologous syngeneic bone marrow transplantation and immunotherapy of stem cell transplantation on the prognosis of mantle cell a murine B-cell lymphoma: active immunization with tumor- lymphoma: a joint analysis of two prospective studies with derived idiotypic immunoglobulin. Blood. 1990;76:2411-2417. 46 patients. Hematol J. 2000;1:87-94. 42. Mackall CL, Bare CV, Granger LA, Sharrow SO, Titus JA, 52. Freedman AS, Neuberg D, Gribben JG, et al. High-dose che- Gress RE. Thymic-independent T cell regeneration occurs via moradiotherapy and anti-B-cell monoclonal antibody-purged antigen-driven expansion of peripheral T cells resulting in a rep- autologous bone marrow transplantation in mantle-cell ertoire that is limited in diversity and prone to skewing. J Immu- lymphoma: no evidence for long-term remission. J Clin Oncol. nol. 1996;156:4609-4616. 1998;16:13-18. 43. Inoges S, Rodriguez-Calvillo M, Zabalegui N, et al. Clinical 53. Ganti AK, Bierman PJ, Lynch JC, Bociek RG, Vose JM, benefit associated with idiotypic vaccination in patients with Armitage JO. Hematopoietic stem cell transplantation in mantle follicular lymphoma. J Natl Cancer Inst. 2006;98:1292-1301. cell lymphoma. Ann Oncol. 2005;16:618-624. 44. Navarrete MA, Heining-Mikesch K, Schuler F, et al. Upfront 54. Haas R, Brittinger G, Meusers P, et al. Myeloablative therapy immunization with autologous recombinant idiotype Fab frag- with blood stem cell transplantation is effective in mantle cell ment without prior cytoreduction in indolent B-cell lymphoma. lymphoma. Leukemia. 1996;10:1975-1979. Blood. 2011;117:1483-1491. 55. Kroger N, Hoffknecht M, Dreger P, et al. Long-term disease- 45. Levy R, Robertson MJ, Leonard J, Vose JM, Denney D. Results of free survival of patients with advanced mantle-cell lymphoma a phase 3 trial evaluating safety and efficacy of specific immuno- following high-dose chemotherapy. Bone Marrow Transplant. therapy, recombinant idiotype (ID) conjugated to KLH (ID-KLH) 1998;21:55-57. with GM-CSF, compared to non-specific immunotherapy, KLH 56. Stewart DA, Vose JM, Weisenburger DD, et al. The role of high- with GM-CSF, in patients with follicular non-Hodgkin lymphoma dose therapy and autologous hematopoietic stem cell transplanta- (FNHL). Ann Oncol. 2008;19(Suppl 4). abstract 057. tion for mantle cell lymphoma. Ann Ooncol. 1995;6:263-266. 46. Pettengell R, Schmitz N, Gisselbrecht C, et al. Randomized 57. Geisler C, Kolstad A, Laurell A, et al. Nordic MCL2 trial of study of rituximab in patients with relapsed or resistant follicular 1st-line intensive immunochemotherapy and autologous stem lymphoma prior to high-dose therapy as in vivo purging and to cell transplantation in mantle cell lymphoma: still encouraging maintain remission following high-dose therapy. J Clin Oncol. results after median 5 1/2 years observation time. Biol Blood 2010;28(Suppl 15). abstract 8005. Marrow Transplant. 2011;17(Suppl 2):S196.